Senior Auditor, Stoploss Claim

BlueCross BlueShield of South Carolina

Auditor handling medical stop loss claims reimbursement for BlueCross BlueShield. Effectively mitigate claims and provide excellent customer service to clients.

Posted 6/11/2026full-timeHawaii, Utah, Vermont • 🇺🇸 United StatesSenior💰 $51,107 - $97,729 per yearWebsite

About the role

Key responsibilities & impact

Audit and authorize reimbursement of specific medical stop loss claims
Effectively mitigate client medical stop loss claims and provide excellent customer service
Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier
Recognize cost mitigation opportunities
Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits
Initiate claims investigations and vendor referrals
Interpret plan language and identify experimental services and subrogation opportunities
Identify need for follow-up on pended claims and resolution
Communicate effectively with carriers, vendors, and management
Provide full claims service to both phone and written inquiries
Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history
Develop new and review old stop loss claim forms
Assist with internal auditing of claims auditors and training of claims auditors

Requirements

What you’ll need

Associate's degree
6 years of managed care or reinsurance claims experience
Analyzes laws, regulations, and contract language
Evaluates issues and develops recommendations
Handles confidential and sensitive information
Investigates assigned claims
Proposes claims adjustments and refunds
Works claims caseloads

Benefits

Comp & perks

Subsidized health plans
Dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims analysisclaims adjudicationcost mitigationclaims investigationsclaims adjustmentsreimbursement processingstop loss claims managementcontract language interpretationauditingreport generation

Soft Skills

customer servicecommunicationproblem-solvingconfidentialityrecommendation developmentorganizational skillsattention to detailtraininginterpersonal skillsfollow-up